Provider Demographics
NPI:1306878202
Name:WILKES, SHANNA L (APN)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:L
Last Name:WILKES
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CENTRE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2862
Mailing Address - Country:US
Mailing Address - Phone:731-512-0104
Mailing Address - Fax:731-668-7388
Practice Address - Street 1:17 CENTRE PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-512-0104
Practice Address - Fax:731-668-7388
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12114363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ72968Medicare UPIN
TN3643961Medicare ID - Type UnspecifiedPROVIDER NUMBER